Federal electronic health record (EHR) implementation incentives available through Medicare and Medicaid count any M.D. or D.O. eligible. Doctors of dental surgery and dental medicine, podiatrists, optometrists and chiropractors are likewise eligible. This opens the floodgates for hundreds of specialists and subspecialists.

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In 2010, before stage 1 was finalized, Halamka's conference presentations frequently illustrated the square peg/round hole nature of meaningful use compliance for specialists by pointing out how early drafts of the rule required recording the smoking status all patients. That, theoretically, meant neonatal ICU doctors would have to record the smoking status of newborns. In the final edition, CMS amended the rule to "patients 13 and older."

Another is e-prescribing. The labyrinthine network of rules and exceptions can be confusing, especially for specialists who write enough prescriptions during a reporting period (100) to be required to report for this meaningful use criterion, but still are generally low-volume prescribers who might not rack up enough to count toward compliance. Immunization registry and public-health reporting requirements can also be anything but straightforward for physicians who are supporting diagnoses, not originating them.

Take, for instance, nephrologists. Jason Holcomb, director of business development for Health IT Services Group (HITSG) -- whose Acumen EHR caters to the kidney specialists -- explained that their patients tend to be older, sicker and generally less aware of their surroundings than the average family practitioner's patients, who tend to be younger and have more hope of improving their health.

Many patients first meet their nephrologist during an emergency room consult -- that is, if they're even conscious. Half of patients who start dialysis do not survive 90 days, Holcomb said.

"[Nephrologists are] dealing with people with chronic kidney disease, renal failure and with traumatic injuries to the kidney," he continued. "It's no place you ever want to be, because they're dealing with some of the sickest people out there. It's a harsh environment."

Acumen is the biggest nephrology-specific EHR, save for one competitor. The other EHR systems for nephrology are modules that large vendors attach to hospital-wide EHR systems. That's if EHR vendors offer a module at all -- since nephrology accounts for about 1% of U.S. physicians, some vendors skip kidney specialists altogether.

As Holcomb sees it, the Office of the National Coordinator for Health IT did, too. "When ONC set out to create [meaningful use] criteria, they didn't think of nephrologists at all," Holcomb said. The nation's two largest dialysis providers, as well as the Renal Physicians Association, have lobbied the ONC's parent organization, the Centers for Medicare and Medicaid Services (CMS), to relax some of the eligibility rules so more nephrologists can participate in meaningful use.

Part of the problem is that few EHR applications work well in the lab-results-driven dialysis environment. Another issue is that nephrologists practice at so many different locations that it's hard to meet the eligibility rule mandating that docs must conduct "50% or more of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology."

"It's been an ordeal," Holcomb said. Despite that, about a dozen groups using Acumen have successfully attested to meaningful use, he added. Getting them through meaningful use stages 2 and 3 looks a little daunting, though, "because there are an awful lot of unknowns….At this point no one knows what stage 2 looks like."

For small practices, good relationship with EHR vendor helps

Other specialists have had an easier time. Barbara Fahl-Watkins, administrator at Heart & Vascular Center of Arizona, was able to get four of the eight cardiologists in her group practice successfully attested for Medicare meaningful use stage 1 on the first day they were eligible to do it.

Tasks such as capturing vital signs and medication allergies have been part of the cardiologist's routine long before CMS wrote it into its meaningful use criteria. "If a patient walks into our office, he's getting a blood-pressure check whether he wants it or not. We're very proactive on some of those things," Fahl-Watkins said.

Besides reporting criteria, another barrier between some specialties and meaningful use compliance is the EHR software itself.

The work involved adjusting the workflow of General Electric Co.'s Centricity EHR to make sure the facility was reporting the right data points to CMS. For example, the facility's standard practice was to take blood pressure readings in each arm. This, Fahl-Watkins said, is a more complete picture than CMS wanted, "and we weren't going to make the change."

"Centricity -- [and] any of the products that are out there -- have been out there for some time, and meaningful use popped up ever so recently," she said. Massaging the everyday data they collect and document to satisfy meaningful use reporting, then, was a six-month process. "Everyone was scurrying to make sure things were being pulled into reports properly. It took a while, it really didn't happen overnight."

Another criterion for which GE had to write specific code was transition of care summaries. While the facility was documenting this all along, it had to capture data in a form reportable to CMS. Specialists, Fahl-Watkins said, need to carefully choose a vendor they can rely on. "In my size practice, I don't have people writing code. My IT staff is from a server and workstation problem standpoint," she said. "My vendor is key to me."

Generally, the CMS meaningful use final rule made it easier for specialists to achieve compliance by making exceptions count. Stage 1 requires physicians to choose five of 10 "menu" criteria, but if three of the 10 objectives don't apply, the physician would only be obligated to meet two other objectives that do apply.

Besides reporting criteria that either doesn't fit their usual workflow or doesn't apply to their patient population, another barrier between some specialties and meaningful use compliance is the EHR software itself.

Because CMS requires the use of certified EHR systems -- and not all EHRs are certified -- a physician may have to choose between a large EHR vendor's certified module, which is not an exact fit for his workflow, and a smaller vendor's well-written application that isn't certified. If that smaller vendor doesn't eventually achieve certification, the physician loses not only the incentives but also will be penalized starting in 2015 if CMS doesn't extend deadlines.

Some specialists may feel they're being dragged into electronic workflows without much incentive beyond CMS's carrot-and-stick EHR Incentive Programs -- in which the carrot is a check for what will likely be some fraction of an EHR implementation's cost, and the stick is the abovementioned disincentives a few years down the road.

However, as Tampa-area family practitioner Pedro Morales, M.D. points out, primary-care docs plugged in to EHR systems will be using clinical decision support tools that make sure patients get referred to specialists for tests such as colonoscopies and mammograms. Specialists who also are plugged in will likewise reap the benefits of EHR systems -- namely, more efficient delivery of electronic personal health information and test results, neither of which requires facilities to pay clerical staff to send faxes.

Morales believes meaningful use will promote needed interaction between primary care docs and specialists -- interaction that was either inconvenient or non-existent before.

For instance, EHR systems can send messages to physicians about referrals or follow-up appointments that patients may have missed. In doing so, Morales said, he can determine if the patient or the specialist is at fault -- the former by not scheduling an appointment, the latter by forgetting to submit test results.